Health care delivery and reimbursement is shifting toward value-based care and vertical consolidation at a rapid pace, while the boom of health plan mega-mergers shows no signs of stopping. Those who want to grow and innovate within this disrupted health care environment face difficult regulatory and transactional legal obstacles. In order to thrive despite these challenges, you must be willing to take calculated business risks and adapt to a shifting landscape.
Creative legal solutions in the most complex markets
Our experienced team anticipates change and crafts creative, strategic solutions in even the most complex markets. Clients turn to us for our depth of knowledge on key issues and our unmatched skill in navigating the complicated industry issues they face, including numerous types of managed care arrangements and integrated delivery systems for health insurers, hospitals, academic medical centers, other institutional inpatient and outpatient facilities, medical groups and independent practice associations, physicians, medical discount programs and employers, as well as for investment bankers, venture capitalists and individual entrepreneurs. Our Firm also works closely with health insurers and their pharmacy benefit managers (PBMs) on prescription drug plans and pricing issues. Amidst uncertainty we offer a level-headed approach, fostering collaboration across industries and borders.
We work tirelessly to facilitate connections through mergers, acquisitions, affiliations and joint ventures, conducting full due diligence while identifying and negotiating arrangements built with regulatory and technological assessments and solutions in mind.
Our team provides guidance to Accountable Care Organizations (ACOs) on the Medicare Shared Savings Program requirements for their organizational and contractual arrangements. We also advise trade associations on communications to their membership regarding legal developments, draft comments on proposed regulations and subregulatory guidance, and offer strategic counseling in dealing with state and federal agencies.
With an impressive depth of national and international regulatory knowledge, we’re at the forefront of health industry innovation. And as the United States’ top-ranked health care law firm, we offer unmatched experience addressing the legal obstacles facing health plans, managed care arrangements and ACOs, including providing counsel on:
Administrative services only arrangements
Requirements under the Affordable Care Act, such as tax issues and risk management
Antitrust and trade regulation
Bankruptcy and workout plans
Consumer-directed health plans
Prescription drug pricing
Conversions and tax-exempt issues
Corporate integrity agreements and compliance programs
The Federal Employees Health Benefits Program
HIPAA privacy and security
Tiered-benefit arrangements and disease management programs
Medical discount programs
The Medicare Advantage Program and Medicare Part D
Federal and state licensure of plans and insurers
Drawing on our robust, cross-functional, cross-border team, we provide cutting-edge solutions and creative counsel to our health plan clients to navigate the changing health care landscape.
Premera Blue Cross, and Providence Health Plan and Providence Health & Services–Washington, with the creation of an alliance to provide a Medicare Advantage Plan for certain counties in the state of Washington
Florida Blue in a variety of matters, including a recent joint venture with Organización Sanitas Internacional, one of the leading providers of prepaid health care in South America, to develop freestanding medical clinics focused on the Hispanic health care exchange market segment
Hometown Health Providers Insurance, a subsidiary of firm client Renown Health, in its acquisition of the assets of OneHealth, LLC, a managed care provider network in the Las Vegas area
New York State Catholic Health Plan, Inc., d/b/a Fidelis Care New York, in the acquisition of CenterCare, a tax-exempt 501(c)(3) prepaid health services plan located in New York City
The Premier ACO Collaborative in a three-year project, assisting approximately 70 health systems develop ACOs
The University of Maryland Medical System (UMMS) in its acquisition of Riverside Health, bringing UMMS into the Medicaid and Medicare managed care market in Maryland
A Hawaii health insurer in drafting and negotiating a global shared risk and accountable care agreement with a large health system
A New Jersey health system on a comprehensive risk-sharing agreement with a large health insurer where the health system would participate as a preferred provider for the insurer’s tiered network product
New England’s largest nonprofit physician-controlled system, a pioneer in managed care and a national leader in the transition to Medicare ACOs, with advice on formation and continued service as principal outside regulatory and transaction counsel
An academic medical center on all aspects of its successful application to participate in the Medicare Shared Savings Program, including corporate structuring and governance, managed care, antitrust, corporate practice of medicine, physician contracting, intellectual property and state managed care law governing risk-bearing organizations
A specialty services provider on a cutting-edge national risk-sharing agreement with a large national health insurer
Several health systems on various aspects of their development of an accountable care organization to apply to participate in the Medicare Shared Savings or Pioneer ACO Programs, including corporate structure and governance, antitrust issues, corporate practice of medicine laws, physician contracting, intellectual property and state laws governing risk-bearing entities
A large for-profit hospital company with developing an ACO model intended for implementation in several states, including the preparation of form participation documents and an administrative services agreement
A large California integrated health system on hospital/health plan joint ventures and related insurance/HMO regulatory matters such as medical loss ratio as well as corporate practice of medicine/fee-splitting and other compliance
Numerous Blue Cross Blue Shield plans on their responses to national data and security breaches involving protected health information (PHI)